Narcolepsy

Narcolepsy is a chronic neurological disorder that affects the region
of the central nervous system that regulates sleep and wakefulness. It
is characterized by a sudden compulsion to sleep and this compulsion shows
up with some regularity. Other names for narcolepsy include
hypnolepsy, sleeping disease, paroxysmal sleep, and Gelineau syndrome.
The disorder affects an estimated 200,000 Americans and symptoms generally
appear in a person’s teens or early twenties.

Narcolepsy is characterized by the following signs and symptoms:

Sudden, uncontrollable episodes of sleep at inappropriate times,
such as while having dinner, talking, driving or working;

Sudden episodes of loss of muscle tone (This can be precipitated
by intense emotion, such as laughter or anger.);

Inpairment in talking or functioning properly when falling asleep
or waking up;

Vivid, often unpleasant, dream-like experiences while falling asleep;

Disrupted nighttime sleep with frequent awakenings;

Performance of routine tasks without memory of the action; and

Learning and memory difficulties

True narcolepsy affects 0.3 to 0.5% of the population, although there
is growing support for establishment of a “narcrolepsy spectrum” with
the people diagnosed as narcoleptics being at one end. The
neurotransmitter class hypocretins seem bound up in narcolepsy, and
patients have lower-than-normal levels in the brain. Indeed, dogs and
mice without hypocretin receptors have narcolepsy, although that
doesn’t mean this is the mechanism that causes narcolepsy in humans.
However, post-mortem studies of the brains of narcoleptics found a
significant reduction in the number of hypocretin neurons.
Nacroleptics have only about a tenth as many hypcretic neurons as
regular people.

It has been hypothesized that the decreased cell number is due to a
mutation in the DNA code for hypocretin but it appears that fewer than
2% of narcoleptics have such a mutation. A degeneration of the
nervous system – a death of relevant cells – seems to be the best
explanation.

Some experts feel that diagnosis rates are as low as 50% of the total
population of patients. The diagnosis may be delayed as much as 10 years
after disease onset due to inadequate patient-physician communication
and/or misdiagnosis.

The causes of narcolepsy are unknown. Recent findings suggest that the
cause may be a damage to some brain cells, in a manner similar to autoimmune
diseases.

Download Narcolepsy, a four-page PDF file
from the National Heart, Lung, and Blood Institute.

Treatments for narcolepsy include medications that improve alertness
and antidepressants to help control cataplexy. Narcolepsy has in the past
been treated with amphetamine or amphetamine-like stimulants, most commonly
methylphenidate (Riatlin), pemoline (Cylert), methamphetamine (Desoxyn),
and dextroamphetamine (Dexedrine). Some patients still take these medicines,
but Provigil has become the standard treatment for narcolepsy. In 2009
the American Academy of Sleep Medicine released guidelines for nacrolepsy
treatment that stated "due to clear evidence of efficacy, modafinil
is regarded as standard treatment for sleepiness in narcolepsy."
Several studies
have found Provigil relieves excessive sleepiness in narcoleptics,
but does not relieve cataplexy.

With good toleration by the body and fewer sympathomimetic and side effects,
Provigil is not a domaminiergic, yet still has a lower potency than the
amphetamine-like stimulants. Provigil is approved by FDA for sleepiness
associated with narcolepsy.

A typical dosage is 200 mg/day. Some patients (with their doctor's approval)
split the dosage to get wakefullness throughout the day.

Sodium oxybate is prescribed for cataplexy and disrupted sleep in narcolepsy.
Stimulants like amphetamines used to be used for nacrolepsy, and to some
extent they still are, but the medical profession now considers the cost-benefit
tradeoff of those drugs to not be favorable, especially now that Provigil
is available.

Obstructive sleep apnea/hypopnea syndrome
(OSAHS)

OSAHS is a serious, potentially life threatening breathing disorder which
affects 6 million adult Americans. Some studies indicate that it is associated
with an increased risk of heart attack and stroke. More common in men
than women, OSAHS is experienced by sufferers as a lack of airflow throughout
the night. This leads to frequent brief arousals. It occurs in 4 percent
of middle-aged men and 2 percent of middle-aged women. Over age 65, the
prevalence rises to 28 percent and 24 percent for men and women respectively.
OSAHS has been the focus of extensive research because of its association
with neurocognitive and cardiovascular complications

OSAHS is characterized by the following symptoms:

Brief interruptions of air flow during sleep and loss of oxygen;

Repetitive arousals, often unnoticed, during sleep;

Falling asleep at inappropriate times during the day, such as while
driving, working or talking;

Early morning headaches;

Depression, irritability and sexual dysfunction; and

Learning and memory difficulties

Patients with obstructive sleep apnea often have residual daytime sleepiness
despite regular use of nasal CPAP therapy. A 2006 guideline
on the U.S. government's website states: "Modafinil is recommended
for the treatment of residual excessive daytime sleepiness in OSA patients
who have sleepiness despite effective positive airway pressure (PAP) treatment
and who are lacking any other identifiable cause for their sleepiness."
Provigil should only be used as a supplementary treatment for OSAHS. It
should not be used as a substitute for the most common treatment for sleep
apnea: continuous positive air pressure (CPAP), a device that keeps air
passages open during sleep and prevents the breathing pauses associated
with the condition.

Shift work sleep disorder (SWSD)

SWSD is a real sleep disorder - not a whiney complaint some people. Workers
who rotate shifts or work at night, such as doctors, police, emergency
personnel, and construction and factory workers. SWSD is a recurring pattern
of sleep interruption from job demands that results in excessive sleepiness
when the person wants to be awake. The body’s natural circadian
rhythms make it difficult for those who don’t work the traditional
9 to 5 hours adjust to their schedule. The human body naturally follows
a 24-hour period of wakefulness and sleepiness that is regulated by an
internal circadian clock that regulates cycles in body temperature, hormones,
heart rate and other body functions. For humans, the desire to sleep is
strongest between midnight and 6 am. Many people are alert in the morning
with a natural dip in alertness in the mid-afternoon. It is very difficult
to reset the internal circadian clock to make those who work at night
feel sleepy during the day and alert at night. An estimated 10 to 20 percent
of night shift workers fall asleep on the job, which not only hinders
their work and makes them more prone to accidents, but makes it difficult
for them to sleep during the day, even though they are tired.

SWSD is primarily experienced by people working at night or individuals
on schedules that require them to work and sleep at irregular times. For
instance, a health care worker on a schedule such as 8 am to 4 pm Monday
and Tuesday and 12 to 8 am Thursday and Friday would be prone to SWSD.
More on SWSD

Is Modafinil ever prescribed for conditions other than the ones
the drug is FDA-approved for?

Provigil is sometime prescribed to people for "off-label"
or “lifestyle” uses, including: